Published by
Stanford Medicine



Addiction, Behavioral Science, Genetics, Research

Alcohol-use disorder can be inherited: But why?

Alcohol-use disorder can be inherited: But why?

man-69287_1280Drop into any support group meeting, and you’ll likely find that many of the addicts there had a parent who was also an addict. It’s estimated that alcoholism (now sometimes called alcohol-use disorder) is 50 percent heritable, although researchers have struggled to identify genes specifically associated with the condition.

The hunt continues for alcohol-use disorder related genes, and a new frontier in the field is the study of the epigenome, a term that refers to inherited changes that affect gene expression, rather than the genes themselves. A new review by a team based at the University of Pittsburgh School of Medicine in the journal Alcohol compiles all that is known about the effects of the epigenome on alcohol inheritance.

“Only recently, with improvements in technology to identify epigenetic modifications in germ cells, has it been possible to identify mechanisms by which paternal ethanol (alcohol) exposure alters offspring behavior,” the researchers wrote.

The basic mechanism is that traits can be passed on through modification of the proteins associated with DNA; these proteins control how genes are expressed. Several studies have examined the role of a father’s alcohol use in the time period surrounding conception, finding their children more likely to suffer from some psychiatric disorders; in research on mice, some effects of paternal alcohol use include low birth weight and decreased grooming. These effects are likely attributed to the alteration of the development of sperm, the researchers write.

Many mysteries remain, leaving plenty of opportunities for additional research. Now, the team is starting to examine how paternal exposure affects offspring’s alcohol consumption.

Previously: Alcoholism: Not just a man’s problem, Could better alcohol screening during doctor visits reduce underage drinking? and Are some teens’ brains pre-wired for drug and alcohol experimentation?
Image by geralt

Addiction, Mental Health, Pain, Public Health, Technology

Student engineers unveil tamper-proof pill bottle

Student engineers unveil tamper-proof pill bottle

Pill-dispenserThe United States has been battling a prescription painkiller epidemic for years. The statistics from the Centers for Disease Control and Prevention are chilling: The number of painkillers prescribed has quadrupled since 1999; more than two million people abused painkillers in 2013; every day, 44 people die from a prescription opioid overdose.

In response, faculty at the Center for Injury Research and Policy at the Johns Hopkins Bloomberg School of Public Health issued a challenge to seniors in the university’s mechanical engineering program: build a pill bottle that would protect against theft and tampering.

One team of students came up with a design that worked so well that their team’s mentors Andrea Gielen, ScD, and Kavi Bhalla, PhD, submitted a proposal to the National Institutes of Health for further testing.

The device is about the size of a can of spray paint, much larger than the average pill bottle. It can only be opened with a special key, which pharmacists can use to refill with a month’s supply of OxyContin. A fingerprint sensor ensures only the prescribed patient can access the pills at prescribed intervals and doses. In a story on the Johns Hopkins website earlier this month, Megan Carney, one of the student engineers described how the pill dispenser works:

The device starts to work when the patient scans in his or her fingerprint. This rotates a disc, which picks up a pill from a loaded cartridge and empties it into the exit channel. The pill falls down the channel and lands on a platform where the patient can see that the pill has been dispensed. The patient then tilts the device and catches the pill in their hand.

A short video about the pill dispenser shows it in action, too. The dispenser still has to undergo additional testing, but the team hopes to bring it to market soon — and help prevent future opioid overdoses.

Previously: Unmet expectations: Testifying before Congress on the opioid abuse epidemic, The problem of prescription opioids: “An extraordinarily timely topic”, Assessing the opioid overdose epidemic, Why doctors prescribe opioids to patients they know are abusing them and Stanford addiction expert: It’s often a “subtle journey” from prescription-drug use to abuse
Photo courtesy of Johns Hopkins University

Addiction, Parenting, Pediatrics, Public Health, Research, Stanford News

Teens confused about harms of marijuana and e-cigarettes, Stanford study finds

Teens confused about harms of marijuana and e-cigarettes, Stanford study finds

smoking-skaterToday’s teenagers are familiar with the dangers of smoking conventional cigarettes, but they’re much less sure of the risks posed by marijuana and e-cigarettes, according to a Stanford study published today in the Journal of Adolescent Health.

The researchers asked 24 high-school students in one Northern California school district about the benefits and risks they perceived from cigarettes, e-cigarettes and marijuana, and where they were getting information about each. The good news is that teens have clearly absorbed the message – from parents, teachers and public health campaigns – that cigarettes are bad for their health. And the kids surveyed saw no benefit to smoking cigarettes, suggesting that conventional cigarettes have lost the “cool” factor they once had among the young.

But there was a big gap in teens’ understanding of e-cigarettes and marijuana, as our press release about the research explains:

“Kids were really good at describing the harmful things that happen with cigarette smoking, but when we asked about other products, there was a lot of confusion,” said the study’s lead author, Maria Roditis, PhD, a postdoctoral scholar in adolescent medicine.

“We’re good at delivering messaging that cigarettes are harmful, but we need to do a better job with other products that teens may smoke,” added Bonnie Halpern-Felsher, PhD, professor of pediatrics in adolescent medicine and the study’s senior author. “We don’t want the message kids get to be ‘cigarettes are bad, so everything else might be OK.’”

Teens need to hear about the risks of marijuana, including its damaging effects on the adolescent brain; its addictive potential; and its ability to damage the lungs, which is similar to that from inhaling smoke from any form of plant matter, Halpern-Felsher said. They also need to hear about the risks of e-cigarettes, which include the addictive properties of nicotine and the fact that flavor compounds in e-cigarettes can cause obstructive lung disease.

In a story about the research on, Halpern-Felsher speculated on some of the factors that may be affecting teens’ views of marijuana and e-cigarettes:

There are several possible reasons why teens may view the risks of smoking cigarettes differently than using marijuana or e-cigarettes. One reason involves advertising — although the tobacco industry can’t advertise on TV, in some print media or in any youth venue, similar restrictions don’t apply to e-cigarettes, Halpern-Felsher told Live Science.

Young people are seeing e-cigarettes in cool colors and cool flavors. They are also seeing celebrities use them, and that gives these products more exposure and makes them appealing, she said.

Previously: With e-cigarettes, tobacco isn’t the only danger, How e-cigarettes are sparking a new wave of tobacco marketing and To protect teens’ health, marijuana should not be legalized, says American Academy of Pediatrics
Photo by James Alby

Addiction, Health Policy, Pain, Public Health

Unmet expectations: Testifying before Congress on the opioid abuse epidemic

Unmet expectations: Testifying before Congress on the opioid abuse epidemic

capitol and Rayburn - 560

My recent trip to Washington D.C. to speak before a congressional subcommittee on the problem of opioid misuse was all about unmet expectations.

First of all, I never expected to get invited to testify for the U.S. Congress. A 2012 article I wrote in the New England Journal of Medicine on the problem of doctors over-prescribing opioids to patients was picked up by Washington Post journalist Charles Lane in a piece he did, “The legal drug epidemic,” which was subsequently read by Alan Slobodin, chief investigative counsel for the House Committee on Energy and Commerce. Slobodin then sent a message to my in-box asking to “discuss the opioid abuse problem.” I almost deleted it as a hoax. But Keith Humphreys, PhD, my mentor and chief of the mental health policy section in our department, assured me it was real.

Second, not really understanding how government works beyond what I learned from the animated musical cartoon “I’m Just a Bill” when I was seven years old, and being a regular reader of the New York Times, which has almost convinced me that everyone in Washington is against everyone else and nothing ever gets done, I prepared myself for the possibility that various members of the committee might just be looking for sound bites to support their pre-ordained opinions. I was wrong.

Slobodin and his staff were curious, earnest, intelligent, and dedicated to understanding the opioid problem at the deepest level. At the hearing itself, where I and other experts testified on the problem of opioid misuse, overdose, and addiction, Congressman Tim Murphy (R-PA), and Congresswoman Diana DeGette  (D-CO) didn’t go for each other’s jugular like a couple of vampires out of Twilight, which I thought might happen. Instead, they were courteous, collegial, and again, struck me as truly dedicated to ameliorating the problem of addiction in this country.

Third and finally, I didn’t imagine that my testimony would make much of a difference, yet some of my suggestions were picked up by members of the committee, including Bridgette DeHart, a senior policy advisor for Congresswoman Yvette D. Clarke (D-NY). DeHart is a whip-smart young woman who in ten minutes of conversation conveyed to me her sophisticated understanding of the opioid epidemic. She talked about incorporating one of my suggestions – mandating physician education on the use of Prescription Drug Monitoring Databases (PDMDs) at the time of DEA-licensure – into a larger bill that Clarke and her team are working on.

Continue Reading »

Addiction, Events, Pain, Patient Care, Public Health, Stanford News

The problem of prescription opioids: “An extraordinarily timely topic”

The problem of prescription opioids: "An extraordinarily timely topic"

photo (2) 2Suffer from pain? Or become an addict? Bemoan the epidemic of pain? Or decry the epidemic of opioid addiction?

At first glance, pain and addiction appear to conflict, to occupy distinct never-overlapping planes. But in reality, pain and addiction anchor two ends of a spectrum, with a lot of gray area in between, said Anna Lembke, MD, director of the Stanford Addiction Medicine Program.

Lembke and Sean Mackey, MD, PhD, chief of pain medicine, squared off in a good-natured debate of sorts moderated by chief communications officer Paul Costello last week at a Stanford Health Policy Forum on “The Problem of Prescription Opioids.”

“This is an extraordinarily timely topic,” Dean Lloyd Minor, MD, said in his introduction. “These issues really reflect a dilemma of wanting to bring the best compassionate care and science to our patients, yet also needing to respect the adverse effects that can occur.”

The statistics on both sides are sobering. The two experts told the audience that in the U.S., more than 16,000 people per year die of opioid overdose and 100 million people live in pain.

And both Lembke and Mackey shared harrowing tales of the suffering of their patients. Lembke once was called to consult on a women suffering from low back pain who had a opioid addiction identified by two previous psychiatrists. Yet in the exam room, the patient threatened to sue if she didn’t receive an opioid prescription, Lembke said. Cases like that prompted her to pen a provocative 2012 essay titled “Why doctors prescribe opioids to known opioid abusers.”

But Mackey treats patients who are suffering deeply, including a woman whose foot injury from a vehicle accident morphed into a pain syndrome affecting her upper extremities.

The current opioid addiction problem stems from a historical pattern of failing to treat pain, even in dying patients, Lembke said. Yet the pendulum swung too far and now doctors feel obligated to prescribe drugs such as opioids, she said.

At the Stanford Pain Management Center, teams of specialists work together to treat pain as a complex condition that affects many parts of the body and mind, Mackey said. Patients are treated with physical therapy, psychiatry and a variety of other specialties to try to allow them to participate in meaningful life activities, he said.

Although care at Stanford is top notch, it is an outlier and thousands of other patients are exposed to poor pain management practices. In addition, pain is now widely recognized as a disease, but addiction remains stigmatized, Lembke said.

When doctors recognize a opioid-seeking patient, they should treat the addiction, not boot the patient out of their practice.

Lembke and Mackey stressed that education about both pain and addiction ought to receive increased attention in medical schools. And patients need to take a role in treating both their own pain, and their addictions, they said. They do share common ground, Lembke said.

“All we think about every day is how we’re going to do it better,” Mackey said.

Previously: Assessing the opioid overdose epidemic, Stanford addiction expert: It’s often a “subtle journey” from prescription-drug use to abuse, Is a push to treat chronic pain pressuring doctors to prescribe opioids to addicts?, Why doctors prescribe opioids to patients they know are abusing them and Study shows prescribing higher doses of pain meds may increase risk of overdose
Photo by Becky Bach

Addiction, Events, Health Policy, Stanford News

Stanford Health Policy Forum to focus on balancing benefits and costs of prescription opioids

Stanford Health Policy Forum to focus on balancing benefits and costs of prescription opioids

6284740462_c1d824cbb7_zNationwide deaths from drug overdose have been steadily increasing since 1990 and are a leading cause of injury death. More than half of drug overdose deaths in the United States are related to pharmaceuticals and 71 percent of these involve prescription painkillers, according to the latest figures from the Centers for Disease Control and Prevention.

In California, the number of deaths involving opioid prescription medications has risen almost 17 percent in the past nine years. As a result, policymakers are struggling to develop methods to reduce the risk of such medications while making sure patients that rely on them for pain management have access.

On April 9, the School of Medicine will host a forum examining the challenges of balancing the benefits and costs of prescription opioids and discussing potential solutions. The event is part of the Stanford Health Policy Forum series and will be moderated by Paul Costello, the medical school’s chief communications officer. Stanford addiction medicine expert Anna Lembke, MD, and pain medicine expert Sean Mackey, MD, PhD, will participate in the forum.

For our local readers: The event, which is free and open to the public, will run from 12:30-2 p.m. in Berg Hall at the Li Ka Shing Center for Learning and Knowledge.

Previously: Stanford addiction expert: It’s often a “subtle journey” from prescription-drug use to abuse, Why doctors prescribe opioids to patients they know are abusing them, Do opium and opioids increase mortality risk? and How to combat prescription-drug abuse
Photo by Erin DeMay

Addiction, Media, Medicine and Society, Mental Health, Technology

Patient tells how social media helped her overcome the “shame” of her eating disorder

Patient tells how social media helped her overcome the "shame" of her eating disorder

3375657138_d025fc4092_bMany of us turn to our friends and families for encouragement when times are tough. So it’s no wonder that social media sites have also become important sources of emotional support for people with illnesses.

Recently, a story over on MindBodyGreen highlighted how one woman used Facebook as a tool to help her overcome the shame and deception that hampered her recovery from her eating disorder. As Lindsey Hall explains:

Two months into rehab, I was still struggling with letting go of the games of my eating disorder. Transitioning from in-patient to out, I’d been rapidly finding myself falling backwards instead of forwards.

Here I was, 24 years old, still living some days bagel by bagel, still opening the door to deception, and guilt and shame. I knew on some level that admitting to my eating disorder on social media would be a way for me to stop the show. I knew I needed to own this struggle in order to own all of myself, and to continue on my journey learning the art of self-acceptance.

As Hall describes in the story, her decision to make her eating disorder public on Facebook was a leap of faith with no guarantee that it was the right thing to do:

I’ll never really know what drove me to write that Facebook status, but I posted it anyway to the open arms of nearly 2,500 “friends” and family, to people that had met me once at a bar or sat next to on a plane. Having lived so long behind a smoke screen, I was ready to expose myself. I needed to feel bare, even while broken, in order to be able to clean my slate, and start from scratch in reconstructing my life.

The feedback Hall received from her gutsy post on Facebook and the subsequent blog posts and stories about her eating disorder haven’t always been positive, but as Hall explains, that wasn’t that point. Hall’s eating disorder is public information now, and this new level of accountability has helped her keep her eating habits on track.

Previously: Incorporating the family in helping teens overcome eating disordersA growing consensus for revamping anorexia nervosa treatmentPossible predictors of longer-term recovery from eating disordersGrieving on Facebook: A personal story and How patients use social media to foster support systems, connect with physicians
Photo by .craig

Addiction, FDA, Health Policy, Pediatrics, Public Health

Raising the age for tobacco access would benefit health, says new Institute of Medicine report

Raising the age for tobacco access would benefit health, says new Institute of Medicine report

cigarette packToday, the Institute of Medicine released a new report evaluating the public health effects of reducing teenagers’ access to cigarettes and other tobacco products. Right now, in most places in the United States, you must be 18 years old to buy cigarettes and other tobacco products. But a few states and cities have higher minimums, and in 2013, the IOM convened a committee, at the request of the U.S. Food and Drug Administration, to examine the potential effects of a higher minimum legal age for tobacco access across the country.

The committee, which was led by Richard Bonnie of the University of Virginia and included Stanford adolescent medicine expert Bonnie Halpern-Felsher, PhD, reviewed the existing scientific literature on tobacco use in teens. They also devised mathematical models to predict what would happen if the federal minimum legal age were 19, 21 or 25.

The report brief (.pdf) says, in part:

Based on its review of the literature, the committee concludes that overall, increasing the MLA [minimum legal age] for tobacco products will likely prevent or delay  initiation of tobacco use by adolescents and young adults. The age group most impacted will be those age 15 to 17 years. The committee also concludes that the impact of raising the MLA to 21 will likely be substantially higher than raising it to 19. However, the added effect of raising the MLA from 21  to 25 will likely be considerably less.

The parts of the brain most responsible for decision making, impulse control, sensation seeking, and susceptibility to peer pressure  continue to develop and change through young adulthood, and adolescent brains are uniquely vulnerable to the effects of nicotine. In  addition, the majority of underage users rely on social sources—like family and friends—to get tobacco. Raising the MLA to 19 will therefore not have much of an effect on reducing the social sources of those in high school. Raising the MLA to 21 will mean that those who can legally obtain tobacco are less likely to be in the same social networks as high school students.

Although it can take time to fully realize the benefits of reduced smoking, since heart disease, lung cancer and other diseases linked to smoking take decades to develop, the payoff would ultimately be significant, the report adds:

…if the MLA were raised now to 21 nationwide, there would be approximately 223,000 fewer premature deaths, 50,000 fewer deaths from lung  cancer, and 4.2 million fewer years of life lost for those born between 2000 and 2019.

Previously: How e-cigarettes are sparking a new wave of tobacco marketing, To protect teens’ health, marijuana should not be legalized, says American Academy of Pediatrics and UN’s top health official: Anti-tobacco efforts can lead to better health “in every corner of the world”
Photo by Thomas Lieser

Addiction, FDA, Health Policy, Medicine and Society, Public Health, Public Safety

To keep edibles away from kids, marijuana policies must be “fully baked”

To keep edibles away from kids, marijuana policies must be "fully baked"

sanfran031606_fig1_highresDepending on your position, legal marijuana might raise images of stoners on every street corner or of users enjoying a private puff in their backyards. However you probably don’t picture a child munching on a pot-laden brownie she found in her kitchen cupboard.

But as Stanford legal experts Robert MacCoun, PhD, and Michelle Mello, JD, PhD, point out in a commentary published today in the New England Journal of Medicine, the loose state regulation of marijuana edibles creates some unnecessarily and potentially serious public health risks that should concern everyone.

Packaged in brightly colored wrappers, edibles often mimic popular sweets, but they contain a powerful dollop of tetrahydrocannabinol (THC), the chemical responsible for marijuana’s psychoactive effects. Some edibles contain multiple “servings” of THC per package.

Both Colorado and Washington — the two states with legal recreational marijuana — require “child-resistant” packaging and a warning to “keep out of the reach of children.” But edibles remain quite attractive to children, who may confuse them with regular candies and snacks, and potentially deceptive to adults, who may assume one bar is a just one serving. “I look at these packages and I get hungry just looking at them,” MacCoun said.

The edibles are not regulated as either a food or a drug by the U.S. Food and Drug Administration, because the federal government considers marijuana illegal. Legalizing states have been slow to fill the gap, and have done so incompletely, Mello said. “This is sort of a weird space that’s betwixt and between federal and state oversight,” she said.

It’s time for the medical community to get involved, MacCoun said. “Most people don’t understand the brain metabolizes chemicals ingested by mouth differently than those smoked.”

Ingested marijuana offers a delayed high, so people keep eating thinking they are fine. The intoxication lasts longer and is associated with more hallucinations and perceptual distortions, he said. “It’s almost like a different drug.”

For now, the issue is most pressing in Colorado and Washington, but many other states are considering legalizing recreational marijuana, including California, MacCoun said.

“We’re not taking some strong position these products should be banned. Sensible and fairly modest regulations would reduce the risk without greatly restricting people’s freedom to consume these products,” MacCoun said.

Previously: Discussing the American Academy of Pediatrics’ call to put the brakes on marijuana legalization, To protect teens’ health, marijuana should not be legalized, says American Academy of Pediatrics and Medical marijuana not safe for kids, Packard Children’s doc says
Photo by DEA

Addiction, Behavioral Science, Ethics, Events, In the News, Media

At Stanford visit, Glenn Beck addresses compassion, change and humility

At Stanford visit, Glenn Beck addresses compassion, change and humility

glennUntil this week, I wouldn’t have associated radio personality Glenn Beck with compassion. And when Jim Doty, MD, director of Stanford Medicine’s  Center for Compassion and Altruism Research and Education invited Beck to the Stanford campus, he realized the right-of-center author and provocateur might be a tough sell to his audience accustomed to guests such as the Dalai Lama and Sri Sri Ravi Shankar.

“Please trust me,” Doty tweeted last week.

Yet fireworks were absent from the nearly two-hour conversation, which ranged from Beck’s struggle with addiction to his Mormon faith and his passion for radio.

Beck came across as human, a man who had endured struggles, made mistakes and is striving to learn from them. He is a father and husband, who organizes charity efforts and volunteers in his church. He said he’s gone from a person for whom the audience size was just a measure of his success to a man who cares deeply about people and his audience members. He prays for humility and said he is not trying to be divisive.

“I spend a lot of time, at the end of my day, saying, ‘Okay, am I that guy? What could I have done better,'” Beck said. “You self-examine all the time and with that self-examination you grow. It’s good. I know who I am because I’m pushed up against the wall all the time.”

Americans share a certain set of principles in common, Beck said. The rift begins when people replace their principles with specific interests and policies.

“For example, if I said to you, ‘Do we torture?’,” Beck said. Nearly everyone would say no. But once threats from terrorists are introduced, the conversation becomes more divided.

“The left and the right have principles in common. We may disagree on interests, but we have to start anchoring ourselves in the principles.”

Continue Reading »

Stanford Medicine Resources: